1881733558 NPI number — AMY KRISTEN MICKLER MD

Table of content: AMY KRISTEN MICKLER MD (NPI 1881733558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881733558 NPI number — AMY KRISTEN MICKLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICKLER
Provider First Name:
AMY
Provider Middle Name:
KRISTEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIDDLE
Provider Other First Name:
AMY
Provider Other Middle Name:
KRISTEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881733558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-793-9300
Provider Business Mailing Address Fax Number:
727-793-0661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 DRUID RD S
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33756-3846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-441-3711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  135564 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME98736 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 278336300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00427228 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 90739 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 278336300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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